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Commentology: The Creative Destruction of Healthcare

Mar 26, 2014• 3

By THCBist

THCB reader and occasional contributor Dave Chase had this to say about Bill Crounse, MD’s recent post “Why the Creative Destruction of Healthcare May Not Be a Good Idea.”

“There is no doubt there are some obnoxious people throwing around arrogant/naive ideas. However, the “creative destruction” and “disruptive innovation” that has been most impactful has come from physician-entrepreneurs. Often, they are the most provocative and hard-hitting in their language.

It seems loosely similar to how the most virulent anti-smokers are former smokers. They want others who they can relate to experience the liberation they’ve experienced.

I wouldn’t assume ill-intent from these MD-entrepreneurs using direct language. They simply were fed up with what they experienced as “broken” and stepped up with approaches that have out-performed.

I’m thinking about the MD-entrepreneurs and innovators who have led CareMore, Nuka Model of Care, Qliance, Iora Health, MedLion, Healthcare Partners, etc. Sometimes to catalyze change, one must use stark, hard-hitting language.

That doesn’t seem like a foreign concept to the many excellent MDs I’ve known over the years. I have enormous respect for any entrepreneur, especially one coming from tradition-bound professions who are willing to stick their neck out and endure enormous personal financial risk.

Bob Margolis shared how his colleagues referred to him as a “communist” and his team-based model as “communism” yet Bob’s org achieved far better outcomes. He had the last laugh when that “communist” sold his business for $4.4B last year.

The comments from these MD-entrepreneurs is they feel they aren’t doing their MD friends any favors by candy-coating what is widely recognized as a system that isn’t close to reaching its full potential.

In contrast, the orgs those MD-entrepreneurs are running are the reigning “Triple Aim Champs” that we should celebrate — colorful language or not. Often the most impactful entrepreneurs aren’t particularly “polite” in their language — Steve Jobs, Bill Gates, Larry Ellison et al called it like they saw it.

What’s wrong with that?”

Actually, It’s a Great Time to Be a Doctor

Mar 26, 2014• 8

By Jeffrey Weisz, MD

Is this a good time to be a physician? Absolutely! In fact, I believe there has never been a better time to practice medicine. I hold this belief despite the barrage of negative comments and predictions from doomsayers remarking on the sorry state of health care in its current state.

Before I tell you why I’m so optimistic, I’d like to acknowledge one fact: practicing medicine is more complex and difficult than ever, however, this fact doesn’t dampen my enthusiasm. There is no doubt that over the past two decades a great many changes in the health care environment have consumed doctors’ time, distracted us from our core task of providing care, and impacted our incomes.

Meanwhile, patients’ expectations of the health care industry and of their physicians are changing. An increasing number of people want more involvement in their own health care and want to partner with their physician. So it is not hard to understand how practicing medicine can feel more challenging than ever.

For example: results from a national survey reported in the Archives of Internal Medicine in 2012 indicated that US physicians suffer from more burnout than other American workers.

Burnout, in this report, was defined by “loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment”; 45.8% of responding physicians had at least 1 of these symptoms.

So why am I so optimistic?

Because when I read these survey results, and others like them, bureaucracy and complexity are often cited as the reasons why physicians are unhappy. Not patient care.

While these factors (bureaucracy and complexity) can momentarily take physicians away from their passion of practicing medicine, it is the passion of a physician, precisely, that fuels my optimism for the state of health care today.

What If Your Employer Gets Access to Your Medical Records?

Mar 25, 2014• 22

By Vik Khanna & Al Lewis

T was never a star service tech at the auto dealership where he worked for more than a decade. If you lined up all the techs, he wouldn’t stand out: medium height, late-middle age, pudgy, he was as middle-of-the-pack as a guy could get.

He was exactly the type of employee that his employer’s wellness vendor said was their ideal customer. They could fix him.

A genial sort, T thought nothing of sitting with a “health coach” to have his blood pressure and blood taken, get weighed, and then use the coach’s notebook computer to answer, for the first time in his life, a health risk appraisal.

He found many of the questions oddly personal: how much did he drink, how often did he have (unprotected) sex, did he use sleeping pills or pain relievers, was he depressed, did he have many friends, did he drive faster than the speed limit? But, not wanting to rock the boat, and anxious to the $100/month bonus that came with being in the wellness program, he coughed up this personal information.

The feedback T got, in the form of a letter sent to both his home and his company mailbox, was that he should lose weight, lower his cholesterol and blood pressure, and keep an eye on his blood sugar. Then, came the perfect storm that T never saw developing.

His dealership started cutting employees a month later. In the blink of an eye, a decade of service ended with a “thanks, it’s been nice to know you” letter and a few months of severance.

T found the timing of dismissal to be strangely coincidental with the incentivized disclosure of his health information.

TED 2014: Flip the Clinic!

Mar 25, 2014• 1

By Michael Painter, MD

First, let’s get the plug out of the way, shall we? Here’s the deal: The Robert Wood Johnson Foundation has a new initiative, Flip the Clinic—and we want you to join us.

We’re launching the new Flip the Clinic site this week. Here’s the trailer. Please take a look, and then let me know what you think:

[vimeo=89722532]

So, what’s with all this flipping business? What’s all this talk about health conversations?

The Note Taker’s Dilemma

Mar 25, 2014• 7

By Saurabh Jha, MD

The year is 2020, or sometime in the future when the healthcare system is better, much better. Patients have access to their medical notes, are encouraged to read the notes regularly and ask physicians relevant questions. This is to facilitate patient-centered participatory medicine (PCPM), previously known as shared decision making. In fact, note reading by patients is now a quality metric for CMS.

The CEO of the Cheesecake Hospital Conglomeration, one of the hospital oligopolies, has set up a Bureau for Transparency and Protection of Patients from Complex Medical Terminology. The goal is to risk manage troublesome medical writing that could result in poor satisfaction scores, complaint or a lawsuit.

Mr. Upright (MU) is the Inquisitor General for the bureau. He has called the author (SJ), a repeat offender, to his office to discuss elements of his medical record keeping.

Disclaimer: Any resemblance to future events is purely coincidental. The narration is merely a reflection of the author’s paranoid affect and a tendency to believe in conspiracy theories.

MU: Dr. Jha, you’ve been summoned because your open medical notes do not meet the standards for empathy and compassionate care and seem devoid of a reflection on the complex interplay between social determinants of health.

SJ: Has a patient complained?

MU: No. But that’s what the bureau is trying to prevent. We protect patients from physicians. Actually, we protect physicians from their most dangerous enemy: themselves.

What Makes a Good Doctor? And Can We Measure It?

Mar 22, 2014• 40

By Ashish Jha, MD

I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?

In thinking about this, I reflected on how far we have come on quality measurement. A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse. Yet, in the last decade, we have seen a sea change.

We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay. But the unease with quality measurement has not gone away and here’s why. If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria: good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes.

Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.

So where’s the disconnect? What does make a good doctor? Unsure, I asked Twitter:

Over 200 answers came rolling in.
Continue reading…

TED2014: Grandmother Avatar with TB Beckons Medical Education Her Way

Mar 21, 2014• 6

By Michael Painter, MD

Why should I be in the same room with these people?

That’s one of the many smart questions participants posed at a Stanford Medical School meeting I attended last weekend. If I had been daydreaming (I’d never do that), I might have thought the question was for me. You see, the participants were a handpicked set of national medical education experts, folks nominally from the status quo medical-education-industrial complex—the very thing we’re trying to change.

You might think that they embodied that dreaded status quo. I’m happy to report they did not—not even close. I’m also relieved to tell you that the question (in spite of my paranoia) wasn’t for me. Instead, it was one of many challenges these thoughtful, passionate teachers tossed at each other.

“Why are we in the room?” was a challenge to each other. Why and when should teachers be in the same room with the learners?

When you think about it, that’s actually a central question if you’re attempting to use online education to flip the medical education experience. It’s also a brave one if you’re a teacher: justify the time you spend with your students.

McNutt-Hadler Credo for Value-Laden Medical Decision Making

Mar 21, 2014• 25

By ROBERT McNUTT, MD and NORTIN HADLER, MD

Robert McNutt and Nortin Hadler respond to med student Karan Chhabra’s original post, “Actually, High Tech Imaging Can Be High Value Medicine” and the resulting discussion thread.

Thank you for your comments. First, we are happy you are so interested in medical practice and how to do it better. Please do not think for one second that our comments are critical of you.

However, since you persist in thinking that money matters, that you have the right to think that way during your care of a patient, and that economic principles help patients, let’s look again at this issue you have raised.

Nearly 20 years ago, Hadler published his first “Four Laws of Therapeutic Dynamics” (JOEM 1997; 39:295-8):

1) . The Death Rate is One per Person

2) . Never Poke a Skunk

3) . There has Never been a Quack without a Theory

4) . Institutions Die; People Live

Now we present, for the first time ever, the econometric corollaries, the McNutt-Hadler Credo for Value-laden Medical Decision Making:

1) Don’t think of money; think of what the money buys. No patient should be offered a pig-in-a-poke.

2) Don’t think for one moment that medical pricing is rational, let alone market driven. Medical pricing is designed to serve the greed of stakeholders, greed that seems to know no ethical boundaries. Caveat emptor is no match for “common practice” The only way the “consumer” stands a chance is if there are physicians committed to explaining the basis for clinical decisions in an unbiased, transparent, and ethical fashion.

3) If it doesn’t benefit the patient, we don’t care if they give it away – don’t prescribe or order it. (For example, no stable in-patient should have any of the following tests: amylase or lipase; any test for iron deficiency other than the ferritin; CRP, BNP, MRI after a CT of the head, or any chronic care medicine like a statin, iron tablet, heart healthy diet in a cancer patient, vitamin, a blood pressure medicine that costs more than the cheapest alternative, a non-generic medicine that is available in generic form, enteric coated aspirin, or bone scans in women looking for osteoporosis)

Republicans Considering Proposing High-Risk Pools: Health Insurance Ghettos???

Mar 20, 2014• 2

By Robert Laszewski

We are hearing that Republicans are considering proposing high-risk pools as part of an alternative health insurance reform proposal to Obamacare.

A high-risk pool proposal would likely mean the Congress giving states the flexibility, and perhaps funding, to set up these risk pools. Risk pools by definition are a place where people can go when they are not able to buy health insurance in the regular market because they have a health problem.

That means Republicans would be turning the clock back to a time when insurance companies could turn people down for health insurance because of their health status.

Presumably, the Republicans are contemplating a market where insurance companies could once again choose just who they wanted to cover––the healthy but not the sick.

Anyone turned down could then go the high-risk pool to be assured of having health insurance. Presumably, Republicans would assure consumers that they would be able to access the same kind of comprehensive health insurance and at the same market rates as those able to buy from insurance companies would be able to get.

Let me be clear at this point that I don’t know of anyone in the insurance industry asking to go back to the days when a carrier could exclude people as a result of their health status and make money just covering the healthy.

Whether it’s Obamacare or a risk pool concept, policymakers are faced with the same dilemma: How do you insinuate the unhealthy and otherwise uninsurable into a health insurance system in a way that benefits are comprehensive and costs are affordable for everyone?

The Oncologist’s List

Mar 19, 2014• 1

By James Salwitz, MD

Lists guide our lives. Some are easy, even fun, like a menu or shopping list. Some are simple tick-offs for work, like my wife’s honey-do list. Others are frightening, like a draft list.

Some are melancholy, such as the inventory in a Will. We are inspired by our bucket-list. Finally, some are exciting, but stir conflict, like awedding invitation list.

I have a list, which makes me slightly anxious, a little depressed, and which takes modest courage to open up. That is my patient’s list of daily X-ray reports.

Our Electronic Medical Record (EMR), as based around a home page or “Inbox.” This is a continuously updated assembly of data and messages from our practice and patients.

There are medical orders to approve, questions from nurses and patients, billing inquiries, documents to sign, lab results and emergency alerts about patients in trouble.

Except for the drudgery of pushing through a pile of CMS documentation, those lists have scant emotional impact on me. Not so the eighth list, just four from the bottom: Radiology Documents.

These are the results delivered electronically of any MRI, CT scan, bone scan, chest X-ray or other imaging study, that I, or other doctors, have ordered on my patients. Every 24 hours, between 15 and 30 new reports pop-up.

Opening this section I see three columns; the patient’s name, the date the test was performed, and the type of test.

One click on each line yields a neat, formatted, typed report. These are more than just data. More than simple facts. These are final, cold, hard answers to the biggest questions of all.

Is Sue’s cancer is responding to therapy? Does Pete’s shortness of breath mean “just” pneumonia or a blood clot, or has his kidney cancer has metastasized to his lungs? Did Sid pull his back shoveling snow or is that sharp pain a vertebra fractured by prostate cancer?

Is Alan’s forgetfulness fatigue, Alzheimer’s or perhaps something more insidious, the bloom of glioma cells deep in his brain?